Comparison of Acute Health Care Utilization Between Patients Receiving In-Center Hemodialysis and the General Population: A Population-Based Matched Cohort Study From Ontario, Canada.

Background: Patients receiving maintenance hemodialysis have multiple comorbidities and are at high risk of presenting to the hospital. However, the incidence and cost of acute health care utilization in the in-center hemodialysis population and how this compares with other populations is poorly understood. Objective: To determine the rate, pattern, and cost of emergency department visits and hospitalizations in patients receiving in-center hemodialysis compared with a matched general population. Design: Population-based matched cohort study. Setting: We used linked administrative health care databases from Ontario, Canada. Patients: We included 25 379 patients (incident and prevalent) receiving in-center hemodialysis between January 1, 2010, and December 31, 2018. Patients were matched on birth date (±2 years), sex, and cohort entry date using a 1:4 ratio to 101 516 individuals from the general population. Measurements: Our primary outcomes were emergency department visits (allowing for multiple visits per individual) and hospital admissions from the emergency department. We also assessed all-cause hospitalizations, all-cause readmissions within 30 days of discharge from the original hospitalization, length of stay for hospital admissions (including multiple visits per individual), and the financial cost of these admissions. Methods: We presented the rate, percentage, median (25th, 75th percentiles), and incidence rate per 1000 person-years for emergency department visits and hospitalizations. Individual-level health care costs for emergency department visits and all-cause hospitalization were estimated using resource intensity weights multiplied by the cost per weighted case. Results: Patients receiving in-center hemodialysis had substantially more comorbidities (eg, diabetes) than the matched general population. Eighty percent (n = 20 309) of patients receiving in-center hemodialysis had at least 1 emergency department visit compared with 56% (n = 56 452) of individuals in the matched general population, over a median follow-up of 1.8 years (25th, 75th percentiles: 0.7, 3.6) and 5.2 (2.5, 8.4) years, respectively. The incidence rate of emergency department visits, allowing for multiple visits per individual, was 2274 per 1000 person-years (95% confidence interval [CI]: 2263, 2286) for patients receiving in-center hemodialysis, which was almost 5 times as high as the matched general population (471 per 1000 person-years; 95% CI: 469, 473). The rate of hospital admissions from the emergency department and the rate of all-cause hospital admissions in the in-center hemodialysis population was more than 7 times as high as the matched general population (hospital admissions from the emergency department: 786 vs 101 per 1000 person-years; all-cause hospital admissions: 1056 vs 139 per 1000 person-years). The median number of all-cause hospitalization days per patient year was 4.0 (0, 16.5) in the in-center hemodialysis population compared with 0 (0, 0.5) in the matched general population. The cost per patient-year for emergency department visits in the in-center hemodialysis population was approximately 5.5 times as high as the matched general population while the cost of hospitalizations in the in-center hemodialysis population was approximately 11 times as high as the matched general population (emergency department visits: CAN$ 1153 vs CAN$ 209; hospitalizations: CAN$ 21 151 vs CAN$ 1873 [all costs in 2023 CAN$]). Limitations: External generalizability and we could not determine whether emergency department visits and hospitalizations were preventable. Conclusions: Patients receiving in-center hemodialysis have high acute health care utilization. These results improve our understanding of the burden of disease and the associated costs in the in-center hemodialysis population, highlight the need to improve acute outcomes, and can aid health care capacity planning. Additional research is needed to address the risk of hospitalization after controlling for patient comorbidities. Trial registration: This is not applicable as this is a population-based matched cohort study and not a clinical trial.

Contexte: Les patients qui suivent des traitements d'hémodialyse d'entretien présentent de multiples comorbidités et sont hautement susceptibles de se présenter à l'hôpital. On en sait toutefois peu sur l'incidence de l'utilization des soins de santé aigus chez les patients hémodialysés en center, sur les coûts qui y sont associés, ainsi que sur la manière dont cela se compare à d'autres populations. Objectif: Déterminer, dans une population de patients hémodialysés en center, les taux d'hospitalizations et de visites aux urgences, leurs schémas et les coûts qui y sont associés, puis comparer ces résultats à ceux d'une population générale appariée. Type d'étude: Étudede cohorte populationnelle rétrospective. Cadre: Nous avons utilisé les bases de données couplées du système de santé de l'Ontario (Canada). Sujets: Nous avons inclus 25 379 patients (incidents et prévalents) qui recevaient des traitements d'hémodialyse en center entre le 1er janvier 2010 et le 31 décembre 2018. Les patients inclus ont été appariés,en fonction de leur date de naissance (± 2 ans), de leur sexe et de leur date d'entrée dans la cohorte, à 101 516 individus de la population générale dans un rapport de 1:4. Mesures: Nos principaux critères de jugement étaient les visites aux urgences (en permettant plusieurs visites par personne) et les admissions à l'hôpital à partir de l'urgence. Nous avons également évalué les hospitalizations toutes causes confondues, les réadmissions toutes causes confondues dans les 30 jours suivant le congé initial, la durée du séjour (en comptant les visites multiples par personne) et les coûts associés à ces admissions. Méthodologie: Nous avons présenté le nombre, le pourcentage, la médiane (25e et 75e percentile) et le taux d'incidence par 1000 années-personnes pour les visites aux urgences et les hospitalizations. Les coûts de santé par individu associés aux visites à l'urgence et aux hospitalizations toutes causes confondues ont été estimés en multipliant la pondération du volume des ressources par le coût pondéré par cas. Résultats: Les patients hémodialysés en center présentaient beaucoup plus de comorbidités (p. Ex. diabète) que la population générale appariée. Au cours d'un suivi médian respectif de 1,8 an (25e et 75e percentile: 0,7 et 3,6 ans) et de 5,2 ans (2,5 et 8,4 ans), 80 % (n=20 309) des patients hémodialysés en center ont visité l'urgence au moins une fois, contre 56 % (n= 56 452) des patients de la population générale appariée. Le taux d'incidence des visites aux urgences, en permettant plusieurs visites par personne, était de 2274 pour 1000 années-personnes (intervalle de confiance à 95% [IC 95%]: 2 263 à 2 286) chez les patients hémodialysés en center, soit presque cinq fois plus élevé que la population générale appariée (471 pour 1000 années-personnes; IC95 %: 469 à 473). Les taux d'admissions à partir de l'urgence et d'hospitalizations toutes causes confondues dans la population de patients hémodialysés en center étaient plus de sept fois plus élevés que dans la population générale appariée (admissions à partir de l'urgence: 786 contre 101 pour 1000 années-personnes; hospitalizations toutes causes confondues: 1056 contre 139 pour 1000 années-personnes). La durée médiane des hospitalizations toutes causes confondues par année-patient était de 4,0 jours (0 et 16,5 jours) chez les patients hémodialysés en center et de 0 jour (0 et 0,5 jour) dans la population générale appariée. Le coût par année-patient des visites à l'urgence chez les patients hémodialysés en center était environ 5,5 fois plus élevé que dans la population générale appariée, tandis que celui des hospitalizations était environ 11 fois plus élevé (visites à l'urgence: 1153 CAD contre 209 CAD; hospitalizations: 21 151 CAD contre 1873 CAD [coûts en dollars canadiens de 2023]). Limites: Généralisabilité externe; impossiblede déterminer si les visites aux urgences et les hospitalizations étaient évitables. Conclusion: Les patients hémodialysés en center sont de grands utilisateurs des soins de santé aigus. Ces résultats améliorent notre compréhension du fardeau de la maladie et des coûts associés à cette utilization dans cette population. Ces résultats soulignent également la nécessité d'améliorer les résultats des soins aigus et peuvent aider à la planification des capacités en matière de soins de santé. D'autres études sont nécessaires pour examiner le risque d'hospitalization après la gestion des comorbidités des patients.

Growing home dialysis: The Ontario Renal Network Home Dialysis Initiative 2012-2019.

The Ontario Renal Network (ORN), a provincial government agency in Ontario, Canada, launched an initiative in 2012 to increase home dialysis use province-wide. The initiative included a new modality-based funding formula, a standard mandatory informatics system, targets for prevalent home dialysis rates, the development of a 'network' of renal programmes with commitment to home dialysis and a culture of accountability with frequent meetings between ORN and each renal programme leadership to review their results. It also included funding of home dialysis coordinators, encouragement and funding of assisted peritoneal dialysis (PD), and support for catheter insertion and urgent start PD. Between 2012 and 2017, home dialysis use rose from 21.9% to 26.5% and then between 2017 and 2019 stabilised at 26% to 26.5%. Over 7 years, the absolute number of people on home dialysis increased 40% from 2222 to 3105, while the number on facility haemodialysis grew 11% from 7935 to 8767. PD prevalence rose from 16.6% to 20.9%, a relative increase of 25%. The initiative showed that a sustained multifaceted approach can increase home dialysis utilisation.

High physician adherence to phenotype-specific asthma guidelines, but large variability in phenotype assessment in children.

BACKGROUND: The implementation of international pediatric asthma guidelines hinges on the distinction between intermittent and persistent phenotypes and the prescription of recommended phenotype-specific pharmacotherapy. OBJECTIVES: To ascertain key factors associated with specialist-confirmed phenotype and document physicians' adherence to practice recommendations in an academic pediatric asthma center. DESIGN/METHODS: Using electronic health records, we identified a cohort of children aged 1-17 years who presented to a tertiary-care asthma center between 2002 and 2007 and received a diagnosis of asthma from a pediatric specialist. Outcomes included: determinants of phenotypes and conformity with phenotype-specific treatment recommendations. RESULTS: Of the 3490 eligible children (11,119 visits), most (47%) were preschoolers, 35% were 6-11 years and 18%, 13-17 years. Of children with confirmed asthma, 59% were classified on presentation as having intermittent, 41% as persistent, asthma. The within-patient phenotype varied over time with a consistency index of 0.76 (best=1); the latter was significantly lower in preschoolers than older children (p<0.0001). The persistent phenotype was highly physician-dependent; it was also positively associated with child's age, asthma severity, multiple triggers, calendar year, and duration of follow-up. Compared to 33% of children with intermittent asthma, 82% of those with persistent asthma were prescribed a maintenance controller, most as monotherapy; combination therapy was usually prescribed after a trial of monotherapy. CONCLUSION: Pediatric asthma specialists were highly adherent to phenotype-specific pharmacotherapy. However, even in an academic center, the notable degree of intra-patient and between-physician variation in phenotype, particularly in preschoolers, was an important impediment to prescribing a maintenance controller. The findings underline the importance of developing validated and standardized means of assessing phenotypes, applicable to the whole pediatric age spectrum.

Clinical effectiveness of inhaled corticosteroids versus montelukast in children with asthma: prescription patterns and patient adherence as key factors.

OBJECTIVES: To examine the real-life effectiveness of inhaled corticosteroids (ICS) versus leukotriene receptor antagonists (LTRA) monotherapy in children with mild or moderate asthma. METHODS: Using medical and drug records, we accrued a cohort of 227 children aged 2-17 years, prescribed daily LTRA or ICS monotherapy. LTRA-treated children were matched on age, gender, and previous acute-care visits in a 1:3 ratio to ICS-treated children. Outcomes included rescue oral corticosteroids, prescription duration and dispensing, acute-care visits, hospital admissions, and ß(2)-agonist use. RESULTS: More ICS- than montelukast-treated children had persistent asthma (73 vs. 50%) and fewer had good asthma control (35 vs. 61%) at baseline, suggesting residual confounding by indication. Physician prescriptions covered 62% of the follow-up period for ICS compared to 97% for montelukast (mean group difference [MGD]: -17%, 95% CI: -28%, -7%). In pharmacies, patients claimed 51 vs. 74% of prescribed ICS and montelukast, respectively (MGD = -12% [-20%, -4%]). Consequently, dispensed ICS and montelukast covered 24% and 38% of follow-up period, respectively (MGD = -14% [-22%, -6%]). No group differences in oral corticosteroids (RR = 1.10 [0.66, 1.84]) and acute-care visits (RR = 1.79 [0.96, 3.34]) were observed. ICS-treated children experienced more hospital admissions (RR = 3.63 [1.20, 11.03]) and needed more frequently rescue ß(2)-agonist use of ≥4 doses per week (RR = 2.54 [1.23, 5.23]). CONCLUSIONS: When compared to LTRA, the prescription of ICS monotherapy did not significantly reduce rescue oral corticosteroids or acute care visits and was associated with a higher rate of hospital admission for asthma and rescue ß(2)-agonist use. The findings may be due to paradoxical shorter ICS prescription duration and lower patient adherence, despite more persistent asthma and poorer control than in LTRA-treated children.